- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $467.74 / $1,819.70 / $5,623.41
| Facility | | $467.74 | $1,819.70 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,511.89 / $9,332.54
| Facility | | $2,089.30 | $2,511.89 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $741.31 / $1,737.80
| Professional | | $478.63 | $741.31 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.49 / $1,023.29 / $3,235.94
| Facility | | $158.49 | $1,023.29 | $3,235.94 |